Healthcare Provider Details

I. General information

NPI: 1093408254
Provider Name (Legal Business Name): AMY CAROLYN BULLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY CAROLYN BULLOCK MS, RD/LD

II. Dates (important events)

Enumeration Date: 06/01/2023
Last Update Date: 06/01/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF OKLAHOMA MEDICAL CENTER 700 NORTH EAST 13TH STREET
OKLAHOMA CITY OK
73104
US

IV. Provider business mailing address

18521 RASTRO DR
EDMOND OK
73012-9600
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-8001
  • Fax:
Mailing address:
  • Phone: 405-596-9860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1238
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: